The diagnosis ‘puerperal psychosis’ or ‘puerperal insanity’, as it was termed in the 19th century (Loudon, 1988), refers to a severe mental illness that manifests shortly after childbirth. The puerperium, also known as the postpartum or postnatal period, begins immediately after the birth of the baby and lasts for 6 weeks (Hollingworth, 2016). Puerperal psychosis occurs in this 6-week period, with peak onset usually within 2 weeks of birth; it has a good short- to medium-term prognosis, as most women respond well to treatment and make a complete recovery (Thamban and Naquib, 2016). This condition should be considered part of the psychiatric discipline; however, the consequences of ‘getting it wrong’ can have devastating repercussions for the woman, her child and her family (National Institute for Health and Care Excellence, 2001).
Introduction
George Mora (1965) described modern psychiatry starting at the end of the 18th and beginning of the 19th centuries. This coincided with the publication of Pinel's (1806) ‘treatise on mental diseases’, emphasising Pinel's importance as the initiator of modern psychiatry. Mora (1965) explained that the end of the 18th century was a time of change from ‘unconscious forms of psychological healing in cultures and eras unaware of the importance of psychological problems to the introduction of forms of psychiatric treatment based on the recognition of psychological factors (moral treatment)’.
Pinel's treatise marked what Mora (1965) described as the first of three periods of psychiatric historiography. Similarly at the beginning of the 19th century, ‘puerperal insanity’ became a formal clinical diagnosis against a background of an increasing emphasis on the debility, disease and injury that could befall a woman as a result of childbirth. The term ‘puerperal insanity’ was first adopted in 1819, not by a specialist in psychological medicine, but by Dr Robert Gooch, who was a leading obstetric practitioner in London (Marland, 2012). During the 19th century, the term was adopted by obstetric practitioners and alienists (a former term for psychiatrists) alike.
One of the defining features of puerperal insanity was the likelihood of it being curable. Consequently, there was several stakeholders who vied for the authority to care for these women. Naturally, these included obstetric practitioners and alienists, but general practitioners or family doctors, attending midwives and, in some cases, attending surgeons were all keen to be involved (Marland, 2012).
Puerperal insanity was first described in the psychiatric literature by Esquirol in 1838, who expressed the opinion that the incidence of psychiatric illness following childbirth was much greater than the statistics from psychiatric hospitals would indicate, as many cases were cared for at home (Oates, 2003). A further major contribution was made by his pupil, Marce, in 1857 (Figure 1).
Pre-modern era texts
Prior to 1800, mental disturbances associated with childbirth received scant mention in medical and midwifery texts (Marland, 2003). Introductions to history of medicine always try to identify something relevant written in antiquity, and puerperal insanity is no exception.
The first clinical description of postpartum mental illness often quoted is a case in the third book of epidemics by Hippocrates (Hamilton, 1962). This was the case of a woman with a twin pregnancy who developed restlessness on postpartum day 6, was delirious on day 11, then became comatose and finally died on day 17. Twin pregnancy is linked with a lax uterus after birth and retained products of conception, including blood. This would have been a perfect nidus for infection, especially if there had been some ‘aid’ for delivering the second twin. Delirium is a feature of sepsis and lapsing into a coma is much more in keeping with septic shock, ultimately leading to death. Making a retrospective diagnosis can be fraught with difficulties, but on reviewing the translation of the original text, the author would suggest that the symptoms described and the outcome for the patient were much more in line with puerperal sepsis than insanity (Jones, 1923).
Soranus (1991) has also been quoted as describing puerperal insanity. Reviewing the original text translation, the mania and melancholic madness described in a particular case were associated with menstruation and not related to pregnancy. It was frequent pregnancies that were the predisposing factor for the menstrual problem. This case is a misinterpretation, and the symptoms were more in keeping with premenstrual syndrome. One could argue that menstruation may have been uncommon in antiquity if women were either breastfeeding or pregnant. Thus these descriptions may have been erroneously interpreted to suggest that puerperal insanity was also recognised in antiquity.
Probably the first text that describes puerperal insanity is the medieval diary of Margery Kemp (1373–1439). Margery Kempe was the author of the first spiritual autobiography in English and only personal account of madness by a woman in the Middle Ages (Freeman et al, 1990). She described the difficult birth of her first child and then ‘went out of [her] mind for more than eight months’. She was prevented from seriously harming herself by being tied up and was nursed by attendants during this period (Freeman et al, 1990). Her symptoms have been interpreted as hallmarks of puerperal insanity, a diagnosis not formally used until well after her death. However, Freeman et al (1990) concluded in a well-argued paper that Margery Kempe probably suffered cyclical bipolar disorder and that the pregnancy was a trigger event. This would support the view of Kraepelin, which is discussed later.
Further documentation about mental illness following childbirth was described by Charles Lepois (1611–1675), who considered the cause of this condition to be related to special dark humours. The Galenic theories considered melancholia and mania to be related to an imbalance of the humours, with black bile being associated with melancholy (Freeman et al, 1990).
Beginnings of moral care
During the 18th century, the general public and medical practitioners acknowledged that pregnancy and labour were associated with physical and emotional stress for women. Nevertheless, most literature at that time concerning childbirth and mental disorders remained the domain of practical midwifery (Marland, 2003). William Smellie (1697–1763), the doyen of the British medical profession in the 18th century, produced a three volume ‘treatise on the theory and practice of midwifery’ (Marland, 2003), in which he described some psychological problems. However, he considered them more related to the time of parturition with its attendant stress and difficulties.
William Hunter (1718–1783), an associate of Smellie and another 18th century medical doyen, described the temporary insanity that could overwhelm a woman in the month following childbirth and lead to infanticide (Marland, 2003). In 1798, John Haslam (1798), an apothecary to the Bethlem Hospital, produced his ‘observations on insanity’ observing that more women were afflicted with insanity than men and parturition was an exacerbating factor. He also reported that overall, these women had a good prognosis (Haslam, 1798). Thomas Denman (1733–1815), was the first British ‘man-midwife’ to dedicate serious and detailed attention to mental disorders related to childbearing in his 1801 publication ‘an introduction to the practice of midwifery’ (Marland, 2003).
By the turn of the 19th century, midwifery books started to include descriptions of mania. Samuel Bard (1807) produced a midwifery compendium after his retirement from clinical practice in which he wrote ‘mania is a disease to which pregnant women and particularly childbed women seem particularly disposed’ (Bard, 1807). This compendium, aimed at midwives, students and young practitioners, described various remedies but stated that ‘our practice, therefore is purely palliative and empirical, and we often see the disease subside, after having, in vain exhausted all known remedies’ (Bard, 1807).
Puerperal insanity and moral care
The background observations described above can be compared to Mora's (1965) description of the first period of psychiatric historiography at the beginning of the 19th century, which saw reform of treatment of mental patients. The influence of the innovating spirit of reforms brought about by the French Enlightenment resulted in jettisoning centuries old prejudices and absurd beliefs in favour of new ideas. These centred around a new philosophy of ‘moral treatment’, an approach to mental disorder based on what could now be considered compassionate care (Mora, 1965). This was in stark contrast with the conviction of many alienists at the time, who considered it sufficient for mad people to be locked away and have their symptoms managed ‘by means of barbarous coercion and other cruel measures’ (Neubuerger, 1945). These included chaining patients with iron collars and belts, using terror, cold water, shower baths, darkness and other frightening measures used in the treatment of the insane.
A similar trend occurred in the treatment of puerperal insanity, as ‘moral treatment’ focused on an individualised approach to care of the mother. Denman wrote about this kind of treatment in his ‘introduction to the practice of midwifery’ (Marland, 2003). His advice was for attendants to be mild and kind, as well as watchful, steady and knowledgeable, acquiring almost irresistible control over patients without exerting needless authority (Marland, 2003). One of the main issues at the beginning of the 19th century was related to who would care for these women. Unlike several other patients with psychiatric problems, if satisfactorily managed, these women would have every chance of a good outcome, enhancing the practitioner's reputation.
A key event that affected which professional would dominate the care of pregnant women was the death of Princess Charlotte, the heir to the British throne, in 1817 after her father the Prince Regent (Marland, 2003). Her prolonged, poorly managed labour resulted in the death of three individuals, the princess, her stillborn child and the attending physician, Richard Croft, who subsequently committed suicide. This event reinforced the notion of a woman's frailty, which continued into the Victorian era and allowed the ‘man-midwife’ to gain dominance, particularly in the upper and emerging middle classes. Midwives continued to provide care for the poorer classes.
By the mid 19th century, puerperal insanity had become a recognised condition and considered one of the many ‘disasters’ associated with childbirth. There was a prevailing attitude that women were vulnerable creatures, especially when pregnant; pregnancy was considered an extremely risky condition for both mother and baby. If a woman survived pregnancy, there was the risk of postpartum death from haemorrhage, sepsis or complications of eclampsia (Davis, 2016). The maternal mortality rate only started to decrease in the pre-World War II years (Ministry of Health, 1939). If a woman did survive labour, then the risk of disability was significant, with an estimated 60 000 women per year being damaged or incapacitated as a result of pregnancy, even as late as the 1930s (National Birthday Trust Fund, 1936). Considering these trends, it is perhaps not surprising that obstetric specialists were the main protagonists in the care of women in the puerperium at this point in time.
Gooch led the way in Britain and reported his observations on puerperal insanity in 1820. He made five recommendations on the care of women with puerperal insanity, the most important being to protect the woman from injuring herself. He continued the Galenic tradition, recommending the use of purgatives to evacuate impurities, and while this may seem to be of little therapeutic value today, it probably proved beneficial for the constipating effect of the drugs used to aid sleep, which was another of his five recommendations.
Gooch also recommended monitoring circulation and using antiphlogistic remedies if needed. From current medical practice, any inflammatory process in the puerperium can cause delirium, the signs of which can mirror puerperal insanity. His fifth recommendation was to manage the woman's mind, soothing it during irritation, encouraging it during depression and never attempting to argue with her delusions. He disapproved of bloodletting and the consensus at the time was to provide mild treatments with tonics, calming medicine, nutritious diets (as many of these women were poorly nourished), careful observation, nursing (being cared for) and rest. This was effectively a supportive system of therapy, which was introduced to care for the woman and her baby as she may not have been capable of doing so herself (Marland, 2003).
There was no agreement about the cause of puerperal insanity but there was broad agreement that the 6-week puerperal period marked the time in which puerperal mania could develop. Most cases occurred in the first two weeks after birth, although melancholia could take longer to make itself evident (Marland, 2003). Once diagnosed, decisions needed to be made as to where the woman should be treated. Many stayed at home, although this usually related to the financial situation of the family. It was at this time that the family doctor may have become involved in the care of the woman, with regular domestic visits. Midwifery practitioners emphasised the value of treating the woman in a domestic setting and if not in their own homes, then in another similar type of residence where they could be supported. The overall view was that it was a ‘great mischief to put these women in public or private lunatic asylums’ (Smith, 1856).
Emphasis was placed on curing the woman, whatever her social class, and enabling her to take up her household duties and role as a mother once again. However, one of the features of this condition was that it was no respecter of class and although the management of all women was along similar lines, individual needs were different. Gooch was one of the first to make the link between puerperal insanity and domestic disruption, recognising sleeplessness, as well as deviation of language and behaviour, as early signs of the condition (Marland, 2003). The focus of treatment was to restore order using patience, mild remedies, common sense and ensuring the woman had a familiar routine.
Alienists agreed with this type of regimen, but were more guarded about where women should be treated. Many believed that asylums were not the place for women with puerperal insanity. Nevertheless, if admitted, cases of puerperal insanity helped with asylum numbers when it came to providing figures of curability. Wherever the woman was treated, the surrounding settings were designed to be as close as possible to the woman's own domestic situation, whether at home or in an asylum.
Alienists in the ascendancy
Mora's (1965) second period of psychiatric historiography commenced in the second half of the 19th century, with the establishment and acceptance of psychiatry as a separate specialty of medicine. The management of puerperal insanity also followed that change. By the mid 19th century, the number of women admitted to asylums was increasing and they were increasingly promoted as the proper place to cure these cases (Marland, 2003).
The catalyst for the change in dominance of psychiatry over obstetrics is twofold. The first includes the publication of two seminal psychiatric texts: Esquirol's (1838) ‘des maladies mentales’ (mental illnesses) and his junior colleague Marcé's (1858) publication ‘traite de la folie des femmes enceintes’ (treatment of madness of pregnant women), considered to be the only contemporary comprehensive book on this topic in world literature (Hamilton, 1962). The other significant factor in Britain was the introduction of the 1845 Lunacy Act, which made it compulsory for all counties to establish county asylums (Marland, 2003). This resulted in the development of large institutions with the necessary capacity for dealing with an increasing number of admissions for all psychiatric patients.
William Tuke (1732–1822) was the foremost pioneer championing ‘moral care’ in Britain (Mora, 1965). He was a Quaker and not medically qualified; however, after visiting St Luke's Hospital in London where patients with mental health problems were incarcerated, he set up a retreat in York to provide more humane care for patients presenting with this pathology. The doctors he employed followed more humane regimens of treatment and Tuke's mantle was subsequently taken over by his son and grandson.
John Batty Tuke (1835–1913), one of his relatives, developed psychiatric care in Edinburgh and produced influential papers suggesting that only women with the most severe symptoms should not be treated at home, although early admission, if indicated, was hugely beneficial (Marland, 2003). Once in the asylum, treatment was of a holistic nature, emphasising diet, rest, exercise, encouragement to work and regularity in all these activities. He also emphasised the need to ensure there were no breast or lochial problems, as associated infections may lead to delirium, aggravating the condition (lochia is vaginal discharge after a vaginal birth). Overall, his emphasis was on mild therapies unless the patient was violent and required heavy doses of sedation. Batty Tuke also suggested that patients be invited to speak about their experience and recovery, which he described as like waking from a dream (Marland, 2003). This could be interpreted as an early type of group therapy.
During the 19th century, discussion of puerperal insanity passed from the obstetric and psychiatric literature into forensic texts. Puerperal insanity was used as a common and frequently successful strategy in infanticide and concealment trials (Marland, 2003). This propensity for harmful behaviour by women after childbirth was usually grounds for acquittal. It was in these cases that alienists, midwifery professionals, general practitioners and even surgeons were confident appearing as expert witnesses. Melancholia led to infanticide as a result of apathy and neglect; in the case of mania, it was because of the mother's loss of reason and violent explosive behaviour (Marland, 2003).
Puerperal insanity can be seen as a product of the Victorian era and its actual prevalence is hard to estimate. The available statistics of the time are inkeeping with today's estimates of 1 in 500 pregnancies (Oates, 2003). Marland (2003) explains that case histories and court records give the impression that women were victims not only of their unstable bodies but of social and environmental influences, crippling poverty, hunger, poor home circumstances, ineffectual or violent partners, interfering relatives and being overwhelmed by motherhood. The advantage of an asylum admission was that it took women away from these pressures.
The influence of Kraepelin
In the 19th century, puerperal insanity was thought to be a specific entity distinct from other mental illnesses. However, at the end of the century, psychiatrists such as Bleuler and Kraepelin regarded puerperal insanity as no different from other mental illnesses (Engstrom and Kendler, 2015). This coincided with the change of treatment for more women who were admitted to asylums. The emphasis started to move away from supportive treatment to more aggressive therapies, including force feeding, use of carbolic pessaries and heavy sedation (Marland, 2003). Kraepelin played down the link between mental disease and physical states, urging colleagues to focus on prognosis (Gelder et al, 2001). He suggested that insanity should be divided into two major groups, manic-depression and dementia praecox (subsequently termed schizophrenia). He recommended abandoning the term puerperal insanity, on the grounds that it generally resembled other forms of psychoses (Gelder et al, 2001).
Mora's (1965) third historiographic change in psychiatry was related to the introduction of psychoanalysis. For puerperal insanity, a historiographic change relates to the condition being described as a neuropathic diathesis, which has a hereditary element. In these women, their nervous system was considered to give way as a result of childbirth (Marland, 2003). Interestingly, two major texts on the history of obstetrics make no mention of puerperal psychosis (Graham, 1951; Speert, 2004). Likewise, one of the standard textbooks used by the author's generation of trainees for their professional exams provides barely a page of content about psychiatric disorders in pregnancy, with a caveat that ‘puerperal mental disorder is not an easy subject to grasp’ (Dewhurst, 1981). The impression is that puerperal psychosis has been airbrushed out of existence, especially in the obstetric world.
The 20th century
Despite the apparent decline in interest in the diagnosis, puerperal psychosis became of increased clinical importance. The catalyst for this was the publication of the first confidential enquiry in maternal deaths 1997–1999, which highlighted that suicide in women with puerperal psychosis accounted for 28% of all maternal deaths (Oates, 2003). The report, which is produced triennially, highlighted the severity and early onset of serious postpartum mental illness and the risk of recurrence. It also reported that these suicides were not just ‘cries for help’ but violent deaths. The upshot was the development of screening tools for antenatal patients and training for professionals to be familiar with them. This resulted in earlier referral to mental health teams and an increase in the number of ‘mother and baby’ units, which aim to keep the mother and baby together during their treatment. The National Institute for Health and Care Excellence (2014) also produced guidelines in 2014, updated in 2020, which effectively brought obstetricians and psychiatrists together to provide holistic care for these susceptible women.
Conclusions
The history of puerperal psychosis can be likened to the Cinderella story. It is likely that women throughout the ages suffered mental health problems because of childbirth, and before early modern times, they may have been cared for in their communities, with very little written about the condition and so it was kept in the shadows. This situation changed in the 19th century, as the condition was highlighted and one might say celebrated, until the 20th century when the condition went back into the shadows. Finally, with the publication of the maternal mortality report and the issuing of guidelines, this condition and the women suffering from it have once again been brought out of the shadows, to be identified early and, hopefully, managed appropriately.